Background
Methods
Study design
Settings
Participants and recruitment
Data collection
Data analysis
Results
Participant characteristics
Role | n | |
---|---|---|
Leadership/Management | ||
Ambulatory Clinic Nurse Manager | 4 | |
Director (clinical, nursing, regional) | 3 | |
Coordinator (patient care, program) | 2 | |
Advanced Practice Nurse Educator | 2 | |
Radiation Therapy Lead | 1 | |
Oncologist | ||
Radiation Oncologist | 10 | |
Medical Oncologist | 7 | |
Hematologist Oncologist | 7 | |
Surgical Oncologist | 1 | |
Nursing | ||
Clinical Nurse Specialist/Coordinator | 6 | |
Registered Nurse | 4 | |
Nurse Practitioner | 2 | |
Nurse Navigator | 1 | |
Allied Health | ||
Speech-Language Pathologist | 2 | |
Occupational Therapist | 1 | |
Physiotherapist | 1 | |
Registered Dietician | 1 | |
Social Worker | 1 |
CFIR Construct | Barrier or Facilitator | Description | Example Quote |
---|---|---|---|
Intervention Characteristics | |||
Adaptability | Barrier | • Difficult to tailor the system to the variability of patients, including the treatment options and durations, languages spoken, and comfort with technology. | “There are so many different [clinical] presentations and so many different scenarios. Even once treatment has started, sometimes it’s chemotherapy, sometimes it’s a pill, sometimes it’s antibody therapy, which doesn’t have a lot of side effects.” [Oncologist] |
Facilitator | • Having a flexible system for patients. This includes the flexibility of when patients can register to the system and the ability to access the system on any electronic device. • The ability to tailor the symptoms addressed to the cancer type and treatment status of the patient. • The ability to offer resources through different modes of delivery (e.g., reading material, videos, online and in-person programs). | “I love the idea of constantly reintroducing it and being able to register at different times because maybe chemo is an easy ride, but when you have a bilateral mastectomy, you may need [REACH]. You never know.” [Patient] | |
Relative Advantage | Barrier | • Concerns about the possible redundancy of the system with questions and recommendations from health care providers to manage cancer-related impairments. • Concerns about replacing or decreasing the personal contact and discussions with health care providers. | “These kinds of questions for the symptoms do come up within the course of the days and weeks that they’re here with various members of the team because they have a lot of face-to-face contact with clinicians. So, I guess it’s not very clear whether this is going to be an add-on to the additional dialogue that we’ll be having with patients.” [Radiation therapist] “The conversations and dialogue are essential. I’d be concerned that you’re using technology that’s going to create this algorithm for care that diminishes the personal contact for me with my team.” [Patient] |
Facilitator | • Patients receive an immediate recommendation on the system to manage their symptom(s). • Potential improvements in processes for patients to access cancer rehabilitation resources. • Provides patients with a centralized place to access trustworthy information. | “If they get something directly like tips or resources instead of just creating a body of knowledge, so they feel that they’re getting something back for sharing their information, I can sell that part to a patient.” [Clinical nurse coordinator] “[REACH] is almost getting in the way of Doctor Google, and I really applaud that. It’s kind of a personal resource for information, as opposed to falling down that rabbit hole at 3 in the morning on the internet.” [Patient] | |
Complexity | Barrier | • Concerns about patients’ ability to use the system independently and manage technical challenges or questions patients may have. • Challenges managing concerning symptoms remotely. | “So just noting that in terms of the onboarding and registration of the patients, we need to make sure we have enough support available to the patients and something in the system design that will help them get through that because it sounds like it may be a bit of a hurdle to do the registration piece if it’s not designed properly.” [Oncologist] “Trying to pick up the severe dysphagia of the patients that are actually aspirating is extremely important. But since [REACH] is not generating the [symptom data] to clinicians, isn’t there a risk that patients will say, yes, I’m aspirating, and assume that we know about that because they put it down in the app?” [Speech-language pathologist] |
Facilitator | • Ensure patients are aware of the remote nature of the system and that scores are not monitored by a health care provider. | “I do like the idea of having an alert for the patient, stating they had a sudden increase or drop in this symptom or they’re on one extreme end of the scale, so review this with your physician.” [Clinical site lead and oncologist] | |
Design Quality and Packaging | Facilitator | • The ability for patients to view how their scores compare over time. • The ability to save the resources recommended to view at a later time. • Ensure the resources recommended are up to date. | “I like the option to save that information and not have to go through it all right away. It may be overwhelming if you’re given a bunch of different resources to go through.” [Patient] |
Evidence Strength and Quality | Barrier | • Skepticism of the system’s benefits on clinical and health service outcomes. • Skepticism of the validity of the screening questions patients are asked to complete for each symptom. | “My only concern is, what are the resources on REACH telling them and teaching them?” [Oncologist] “I was just wondering about the symptom selection and the validity of the implementation. Is this the first time this is going to be piloted essentially?” [Speech-language pathologist] |
Outer Setting | |||
Patient Needs and Resources | Facilitator | • The potential to fill gaps in care by providing patients with resources and supports to manage their symptoms. | “Patients can start to feel that disconnection with the cancer center when they’re finishing treatment, and even insecure because they’re going to be back to their regular environment without the support of all the team. So I think it’s really a great project.” [Clinical site lead and oncologist] |
Cosmopolitanism | Barrier | • Concerns about the limited number of rehabilitation services and their capacities to respond to impairments identified by the system. | “The other challenge we have in Newfoundland is we don’t have the portfolio of services that some of the bigger places have to address these issues.” [Nurse practitioner] |
Facilitator | • The potential to build local connections between the cancer centre and community programs and services. | “This project might be able to connect what we have already and to build bridges here locally.” [Oncologist] | |
External Policy and Incentives | Facilitator | • Ensuring institutional departments and teams such as privacy, security, and legal are engaged and that the system meets all necessary standards. | “We have to consider administrative pieces such as whether this information should somehow be part of [a patient’s] medical record, or whether [clinicians] are going be able to access the information patients enter. Or whether there are issues we have to deal with from a privacy and security perspective for us to implement this.” [Clinical site lead] |
Inner Setting | |||
Structural Characteristics | Barrier | • Centers where disease site clinics (e.g., breast, lymphoma) or disciplines (e.g., surgical oncology and medical oncology) are dispersed or located in different settings, may require more time or effort to implement the system due to having different work flows to consider and more staff to engage. • Patients may be receiving treatment (e.g., surgery) at additional sites outside the cancer centre and therefore may have fewer opportunities to learn about the system. | “I just want to point out that here [in the centre], the haematology team is currently outside the cancer program. The haematology team doesn’t use the same area as the other cancer sites and they’re not under the same [organizational] structure.” [Oncologist] |
Implementation Climate (sub-constructs compatibility and relative priority) | Barrier | • Concerns about the potential overlap with existing or upcoming electronic patient-reported outcomes systems used in the setting. • Other initiatives and projects may be prioritized over the system by the setting and delay or hinder the implementation of the system. | “There are many applications, and I worry patients might get mixed up. What if we have patients on treatment that are [on REACH], and they’re answering these questions [on REACH], and they don’t answer their questions on another platform? I worry that patients might get confused.” [Oncologist] “I would suggest not to go live right now. The learning curve for [the new EMR] in the clinics is going to be huge. People won’t have the time or bandwidth for anything else.” [Ambulatory clinic nurse manager] |
Facilitator | • Integrating the approach of registering patients on the system into processes used to communicate with patients and to provide patients with educational materials. | “We have processes for providing patients with information. It might be good if we integrate [REACH] into our existing processes. If a patient is going to start treatment, they get a whole package of information about their treatment. If information about this system was in there, then that might be helpful.” [Ambulatory clinic nurse manager] | |
Readiness for Implementation (sub-construct available resources) | Barrier | • Limited time for staff to introduce the system to patients during clinic visits. • Concerns about the ability for the setting to respond to an increase in patient calls or visits as a result of the system. | “If this has any operational impact on our clinical team, then it’s going to be really hard to move forward and take a lot more time [to implement].” [Site director] |
Individual Characteristics | |||
Knowledge and Beliefs | Facilitator | • Ensuring patients and staff are familiar with the characteristics of the system and how the system is different from other electronic systems used by patients in the setting. | “It would be nice to give us a refresher on the system before the launch. Even to say, okay, these are the types of questions asked and resources that are going to be available in this app. That’ll just help staff get on board.” [Clinical site lead and oncologist] “It would be important to make sure you draw a distinction between the purpose of this system versus the PROMs that we’re doing because you would potentially have patients who would be offered both. At first, [both systems] are going to seem similar, and they might not understand why they’re signing up for two different things.” [Ambulatory clinic nurse manager] |
Process | |||
Engaging (sub-constructs opinion leaders and key stakeholders) | Facilitator | • Ensuring clinic leadership and management are engaged and provide approval to implement the system in the setting. • The ability to receive feedback on how the system can be integrated into the clinic workflow and a patient’s cancer pathway. • Ensuring patients and staff are provided with engaging educational material to improve the adoption and uptake of the system. • Ensuring patients are provided with reminders on the system to complete their symptom reporting. | “For each of the disease site groups, there is a site leadership structure, and any project that anybody wants to do has to go through that structure to determine whether it moves forward.” [Oncologist] “The best way to get people to use [REACH] is to clearly and immediately demonstrate that it has a function for them.” [Patient] “I think it’s better [to introduce REACH] after people have the time to process their whole diagnosis and they’re in a better headspace to sort of open their mind to this.” [Patient] |